Multiple facial bone fractures in a trauma patient

Case contributed by Dr Dayu Gai

Presentation

This 35 yo male rode his motorbike into a car door at low speed (10 km/hour). He was wearing a helmet, although there was significant facial injury. Thin axial slices of the brain and neck are shown.

Patient Data

Age: 35 years
Gender: Male
  1. Comminuted fractures of the anteroinferior walls of both frontal sinuses, on the right extending obliquely through the posterior wall. These fracture lines extend into the nasal process of the frontal bones, with bilateral comminuted nasal bone fractures additionally.
  2. Fracture of the cribriform plate of the ethmoid bone, and the fovea ethmoidalis
  3. Bilateral comminuted fractures through the ethmoid air cells, including the lamina papyracea (medial orbital wall) bilaterally; lateral displacement of the fractured left medial orbital wall.
  4. Fracture of the left lateral orbital wall, and diastasis of the left temporozygomatic suture.
  5. Comminuted fractures of the anterior and medial walls of the maxillary mantra, with mildly comminuted fractures of the posterolateral walls. Extension of fracture into the alveolar process on the right.
  6. Comminuted fractures of the pterygoid processes and the medial and lateral pterygoid plates bilaterally, more severe with marked displacement of fragments on the right.
  7. Bilateral comminuted orbital floor fractures, with depression of the orbital floor, but no herniation of the inferior rectus muscles. Mild extraconal haematoma, and intraorbital air.
  8. Comminuted fracture of the bony nasal septum, with bowing to the right.

Case Discussion

Maxillofacial injuries occur in approximately 16% of trauma patients1 with young males typically involved. The three most common causes of maxillofacial trauma are:

  1. Motor vehicle crashes
  2. Falls
  3. Assault/Interpersonal altercation

Frontal sinus fractures are seen in 5 to 15% of traumatic craniofacial fractures2. As with other craniofacial injury, it is associated with blunt trauma, particularly motor vehicle accidents. Interestingly, the incidence of frontal sinus fractures has decreased recently with the advent of airbag installation in motor vehicles. Nowadays, interpersonal altercation is the most common cause.

Over the last few decades, there has been an increasing tendency to manage frontal sinus fractures conservatively, either without surgery or with endoscopic sinus repair. Features which are indicative for surgery include:

  • A displaced anterior table injury
    • This can pose a cosmetic disfiguration if not surgically corrected
  • Severe posterior table injuries
    • This can cause CSF leak, post nasal drip, or entrapment of mucosa and the formation of mucocoeles
  • Compromised nasofrontal outflow tracts
    • This can also lead to mucocoele formation

Ethmoid fractures are relatively more uncommon, and are found in 5% of adult facial fractures3. Correct management of these fractures is imperative due to late complications, which are largely aesthetic in nature. This includes shortened palpebral fissures, telecanthus and enophthalmos, dystopia and saddle nasal deformity.

Orbital fractures are typically associated with other craniofacial injuries. Evaluation of orbital fractures should involved a careful eye examination, as the risk of concomitant traumatic optic neuropathy, potentially leading to permanent blindness has a 5% incidence4. Indications for operative management of orbital fractures include:

  • Traumatic optic neuropathy
    • Stabilisation of TON with aggressive steroid therapy is indicated prior to surgical management
  • Extraocular muscle entrapment

Case contributed by A/Prof. Pramit Phal.

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Case information

rID: 31700
Case created: 22nd Oct 2014
Last edited: 19th May 2016
Inclusion in quiz mode: Included

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